The healer’s journey-Part 1: How nurses navigate the wake of a mass casualty shooting

On Dec. 2, 2015, the announcement flashed on computer screens at Loma Linda University Medical Center: MASS SHOOTING. THIS IS NOT A DRILL. A few miles from the Southern California hospital, two assailants with assault rifles had opened fire on a local health department Christmas party in San Bernardino, killing 14 people. It was the deadliest shooting in the U.S. since a gunman massacred 20 children and six adults at a Connecticut elementary school three years before.

Loma Linda nurses went into a clockwork formation learned from numerous emergency drills. Within 20 minutes they rolled out a chain of command, cleared rooms, set up triage tents in the parking lot and prepared to receive at least 20 patients. Five arrived. Another 16 went to other hospitals.

Within hours, it was over. The nurses began cleaning up, preparing for business as usual in a busy trauma department that typically deals with traffic accidents and drive-by shootings. “Then,” said James Parnell, MSNc, RN, MICN, the medical center’s director of ED patient care, “the families started to show up looking for their loved ones” — those who had been at the party or in the area of the shooting, but hadn’t been heard from since. People who had checked everywhere for loved ones would come to the hospital hoping more victims would come in.

“That was the hardest part of the day,” said Connie Cunningham, MSN, RN, Loma Linda’s executive director of emergency and trauma services. “In your gut, you know they’re still in the building” where the shooting occurred. “It was the most helpless feeling in the world to say, ‘Your mom is not in the hospital.’” She sat with someone for two hours that afternoon, hoping more victims would arrive. “You’re realizing that everybody who’s left is deceased and there’s nothing you can tell them.”

There were no drills to prepare the nurses for that experience.

Last year, similar scenes played out at Arrowhead Regional Medical Center, where some of the San Bernardino shooting victims were taken; at Mercy Medical Center in Roseburg, Ore., after a shooter killed eight students and a teacher before killing himself on a community college campus Oct. 1; in Charleston, S.C., where eight worshipers were killed in a church and another died on the way to the hospital June 17; and in other communities across the country — Colorado Springs, Col., Chattanooga, Tenn.

Life before and after

Trauma center staff are accustomed to treating people with horrific injuries and comforting grieving families. And statistically, mass casualty shootings are rare compared with other kinds of traumatic events such as large traffic accidents or domestic shootings. Most nurses probably will never have to treat the victims of such an incident or experience the aftermath.

But nurses who have cared for patients after a notorious mass casualty shooting said it feels very different from business as usual. The media attention, the possibility it could have happened to any of them, the fear they may know people involved, the idea that the unthinkable could happen in communities they previously thought of as safe all make a mass casualty shooting especially difficult to understand and process, they said.

ED staff are at risk for secondary trauma after such events, but even hospital staff in other departments can experience feelings such as sleeplessness, sadness, anger and stress, say mental health specialists. As part of a community reeling from shock, healthcare workers must deal with the emotions and stress of their families and friends, as well as their own. The process of acknowledging what has happened and healing may take weeks, months or years after the event and varies greatly according to each person’s circumstances, nurses said. But everyone is affected in some way.
“It’s your life before the shootings and your life after,” Cunningham said.

The importance of preparation

“The importance of hospitalwide disaster training cannot be stressed enough; no emergency department can survive an event like this without the support of the entire institution,” wrote April Koehler, BSN, RN, nurse manager of emergency services at the University of Colorado Hospital in Aurora, Colo. She was describing the hospital’s response to a mass casualty shooting on July 20, 2012, when a gunman opened fire in a movie theater, killing 11 and wounding 58.

The UCH staff had initially been told to expect between three and five patients that night; their already full ED ended up receiving 23, many critically wounded and most of whom were rushed to the hospital in police cars rather than ambulances. One was dead on arrival. Some critical patients were placed in hallways outside already full trauma rooms, according to the article, “Surviving the Dark Night,” by Koehler and two other UCH nurses, published in the Journal of Emergency Nursing in September 2014. ICU nurses joined their ED colleagues caring for critical patients. A post-anesthesia unit was converted to take patients already in the ED. The radiology department, physicians, respiratory technicians, social workers and chaplains pitched in.

The nurse authors credit the hospital’s performance in part to frequent and regular emergency drills, including setting up command centers and arranging patient rooms to prepare for mass casualties. Loma Linda nurses said their drills helped them prepare for many more patients than they actually cared for. At Mercy Medical Center in Roseburg, a rural community hospital, trauma coordinator Lesa Beth Titus, BSN, RN, and her staff were able to set up rooms and assign nine patients, some with multiple critical injuries, as they came in within minutes of each other. Within 45 minutes, all were treated or transferred by air, she said.

“Doing drills can be a chore, but they really prepared us,” said Kimberlee M. Hilty, BSN, RN, house supervisor in charge of trauma center admissions at Banner-University Medical Center in Tucson, Ariz. In 2011, a gunman fired on a gathering for U.S. Rep. Gabrielle Giffords at the entrance to a Safeway. Six people were killed, including 9-year-old Christina Taylor-Green, who died on arrival at the hospital. Eleven were wounded, including Giffords who was shot in the head. Most were taken to Banner UMC.

The hospital called an emergency “Code Purple,” usually activated for things like a bad snowstorm or a roll-over with a group of people in a vehicle, Hilty said. “We’re equipped for these types of events,” she said. “But the part we weren’t equipped for was the aftermath of it because of who it was and the media attention afterward.”

Managing emotions and the media

While the staff at Mercy in Roseburg took care of patients, they had no time to think about the shooting itself. But after patients were stabilized or sent to other hospitals, the horror of what had happened began to sink in, Titus said. “There was lots of standing around and asking questions,” she said.

In Roseburg, where everyone knows everyone, they all had connections to those who survived and those who did not — a babysitter, a daughter’s closest friend.

The Loma Linda staff listened anxiously to the news. The shooters remained at large for several hours after the San Bernardino shooting, and the hospital received a bomb threat at one point. Nurses said they didn’t fear for their personal safety. The hospital was heavily guarded by private and public security. But they worried about the first responders and law enforcement officials, people they knew well, who were still out there. Emotions ran high after a police officer was wounded in a shootout with the assailants, who eventually were killed, Cunningham said.

Nurses also found themselves engulfed in a barrage of media, struggling to protect patient privacy, shielding families and patients from photographers. In some cases, freelance reporters and camera operators tried to sneak into patient rooms. “It was horrible,” Titus said. She understood the media had to report the news, but the national spotlight created stress for the hospital and the community, making people feel constantly on display.

In Tucson, hospital administrators decided to actively involve the media, Hilty said, a strategy she believes worked well. Journalists were housed in the hospital’s cancer center outside the building where patients were recovering, but still on campus. The hospital held daily press conferences, with the same two physicians providing information. “We decided it was best to answer questions and provide accurate information [to journalists], otherwise things got made up,” Hilty said. ”We respected them and they respected us.”

Hospital workers in Roseburg, along with the rest of the town, struggled to make sense of the shooting. The ED had recently treated six victims of a major traffic accident — almost as many as they had after the shooting — but this felt different, Titus said. No one could believe someone in the close-knit community of 22,000 people, would willfully take so many lives for no apparent reason. After the shooting, even a trip to the grocery store no longer seemed safe, she said. “The sense of security has been shaken.”

After the shooting in Tucson, “people needed to come somewhere, do something,” Hilty said. Many came to the hospital. Nurses looked out the windows to see a memorial forming on the lawn. People brought flowers, cards, candles, stuffed animals. A violinist played every night at sunset. The offerings eventually covered an area about the size of a quarter of a football field. “It was very powerful,” Hilty said.

The memorial represented the first step in a community healing process that continues to this day.

One Comment

As a nurse who also received some of the San Bernardino victims, it was business as usual, but it wasn’t. It was probably one of the most stressful days I have had in the OR- waiting for patients, trying to figure out what was happening, processing emotions but working hard to be professional. I work with people who knew not only victims but also the shooter’s family so also supporting those folks too. It was a good while before life returned to “normal”.